RU2285460C2 - Method for surgical treatment of aneurysm of ascending aorta at insufficiency of aortic valve - Google Patents

Abstract

FIELD: medicine, cardiosurgery.

SUBSTANCE: at preoperational period it is necessary to cut three plates out of xenopericardium that correspond to the size of aortic root and in which openings should be made during operation that correspond to mouths of coronary arteries. Then one should fix plates to the mouths of coronary arteries. Then they should be sutured up with double-row mattress suture along the contour of supporting carcass of aortic valve. Depending upon the value of stitch and ligature's tension power, under constant visual control one should regulate the degree of narrowing of fibrous ring and aortic valve by comparing valvular folds against each other. The innovation enables to strengthen the walls of Valsalva's sinuses, keep elasticity and functional characteristics of supporting carcass of aortic root and favors for developing anatomical structure of normal aortic valve.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine and can be used in the surgical treatment of aneurysmal aortic disease.

There is a method of performing valve-saving surgery when the aortic valve cusps are not damaged (Tirone E. David, Feindel, Christopher M. Valve-saving surgery on the aortic valve in patients with aortic insufficiency and ascending aortic aneurysm. J. Thorac. Cardiovasc. Surg. 1992, 103, 617-622). In conditions of cardiopulmonary bypass, the aneurysmal sac is opened longitudinally, the sinuses and mouths of the coronary arteries are excised, leaving the border of the aortic wall. Then, in the area of the excretory tract of the left ventricle, directly under the aortic valve, multiple separate mattress sutures are applied from the inside outwards.

Measure and display the average value of the height of the valves. The radius of the fibrous ring of the aortic valve is taken equal to two-thirds of the height of the sash. And the inner diameter is twice as much. The outer diameter is 4-6 mm larger than the inner. Take a collagen-impregnated cylindrical dacron prosthesis of a vessel with an inner diameter equal to the outer diameter of the aortic root. The proximal end of the prosthesis is sutured with mattress sutures previously placed on the ventricular excretory section. After that, the seams are gently pulled, thus placing the valve in the lumen of the prosthesis of the vessel, the seams are tied outside. Then, the border of the aortic wall along the lower edge of the Valsalva sinuses is fixed with a continuous suture to the vessel prosthesis wall. Using the water load, the valve flaps are checked for consistency. Cut holes in the wall of the prosthesis vessel and impose an anastomosis with the mouths of the coronary arteries.

Restore cardiac activity. The function of the aortic valve is examined using intraesophageal echocardiography.

The method has several disadvantages.

1. When tying the mattress sutures, it is not possible to control the degree of deformation of the aortic root and the correct matching of the aortic valve cusps relative to each other. In this regard, the result of remodeling of the aortic valve is unpredictable.

2. The collagen-impregnated dacron vessel prosthesis is a rigid-wall cylinder that does not have, in contrast to the aortic root, the Valsalva sinuses. The absence of Valsalva sinuses has a negative effect on the function of the valves, since during the systole, vortex flows form between the valves and the wall of the aortic prosthesis, preventing the valves from opening completely, which leads to the appearance of functional stenosis of the aortic valve.

3. Different elasticity of the wall of the prosthesis and the mouth of the coronary arteries causes their aneurysmal expansion.

4. The rigidity of the wall of the dacron prosthesis increases the mechanical load on the flaps, shortens their service life.

5. The presence of synthetic tissue in the blood stream provokes thrombosis and thromboembolism.

The technical result of the implementation of this method is the strengthening of the walls of the Valsalva sinuses, reconstruction of the supporting frame of the aortic root while maintaining its elasticity and functional characteristics, the formation of the anatomical structure of the normal aortic valve.

The method is as follows. In the preoperative period, an echocardiographic examination determines the height of the valves of the aortic valve. Two-thirds of the average height of the valves is taken as the radius of the fibrous ring of the aortic valve. The diameter of the fibrous ring is calculated. Based on the data obtained, plates are cut out from the xenopericardium, the dimensions of which correspond to the aortic root, which is formed during the operation.

In conditions of cardiopulmonary bypass, an aneurysmal sac is opened longitudinally. In the proximal section, the aorta is transversely crossed 5-7 mm above the tips of the commissures. In plates intended for the right and left coronary sinuses, according to the location of the mouths of the coronary arteries, holes of the required diameter are cut out. A continuous twisting seam fixes the plates to the mouths of the coronary arteries. Then, with a double-row mattress suture, the plate is fixed along the contour of the supporting frame of the aortic root, passing along the upper edge of the Valsalva sinuses, commissures and the line of attachment of the valves of the aortic valve. In the distal part of the aortic root, the suture passes through the edge of the plate and the upper edge of the Valsalva sinus. In the area of commissures, the suture passes through the base of the commissure and the edges of the plates of the adjacent Valsalva sinuses. In the proximal aortic root, the suture passes through the plate and base of the sash. Depending on the size of the suture pitch and the tension of the suture under constant vision control, the degree of narrowing of the diameter of the fibrous ring and the aortic root is regulated by comparing the valve flaps relative to each other. Thus, the walls of the Valsalva sinuses are strengthened with xenopericardium plates, the supporting frame of the aortic valve is recreated, and the natural configuration of the aortic root is formed. Using a water load, check the consistency of the valve, then hem the prosthesis of the vessel of the ascending aorta. They restore cardiac activity, examine the function of the valve using intraesophageal echocardiography.

The technical result is achieved by using xenopericardium plates with pre-calculated sizes, from which the aortic root is formed during the operation, as well as by hemming the plates with a double-row mattress suture along the contour of the supporting frame of the aortic root.

Figure 1 presents a plate 1 of xenopericardium with holes 2 for applying an anastomosis with the mouths of the coronary arteries.

Figure 2 presents conventionally in expanded form the aortic root with hemmed plates 1 to the mouths of the coronary arteries with a continuous twisting stitch 3 and a double-row mattress suture along the contour of the supporting frame of the aortic valve 4.

Example.

The heart preparation was obtained from the corpse of a patient who died in a clinic without surgery. Diagnosis: ascending aortic aneurysm, aortic valve insufficiency.

Aneurysmal sac was opened longitudinally. The aorta is transversely intersected 7 mm above the tips of the commissures. Measurements were made of the diameters of the aortic root and the height of the cusps, the results correspond to the data obtained during an echocardiographic study conducted in the clinic: the diameter of the fibrous ring is 32 mm; diameter at the top of commissures 39 mm; sash height 18 mm.

The size of the aortic root, which must be formed during the operation, is calculated. The radius of the fibrous ring is taken to be 2/3 of the average height of the valves, which is 12 mm, and the diameter of the fibrous ring formed during the operation of the aortic root should be equal to 24 mm. The diameter of the aortic root at the level of the apex commissures is 15-20% less than the diameter of the fibrous ring of the aortic valve. Thus, the diameter of the aortic root at the commissure level should be 20 mm, and the circumference should be 62.8 mm.

Three xenopericardium plates with a width of 21 mm each are cut out. The lower edge of the plate is adjusted accordingly to the contour of attachment of the wings. In plates intended for coronary sinuses, holes with a diameter of 10 mm are cut down and fixed to the mouths of the coronary arteries with a continuous twisting seam. Then, a two-row mattress seam fixes the plates along the contour of the supporting frame of the aortic valve. Moreover, in the distal part of the aortic root, the suture passes through the edge of the plate and the upper edge of the Valsalva sinus. In the area of commissures, the suture passes through the base of the commissure and the edges of the plates of the adjacent Valsalva sinuses. In the proximal aortic root, the suture passes through the edge of the plate and the base of the sash, 2-3 mm below the sash attachment line. Under constant vision control, depending on the suture pitch and the tension of the suture, the necessary parameters of the aortic root and matching of the valves relative to each other are achieved.

After completion of the operation, the diameter of the fibrous ring was measured; it was 25 mm; the diameter at the level of commissures was 22 mm. The flaps touch the free edge at a height of 5-3 mm. Under water load, valve failure was not detected. A vessel prosthesis with a diameter of 20 mm was hemmed.

The technical result was achieved by using xenopericardium plates with pre-calculated sizes, from which the aortic root was formed during the operation, as well as by suturing the xenopericardium plates with a double-row mattress suture along the contour of the aortic valve support frame.

Claims (1)

A method for surgical treatment of an ascending aortic aneurysm with aortic valve insufficiency, including determining the diameter of the fibrous ring of the aortic valve, longitudinal opening of the aneurysmal sac, characterized in that in the preoperative period three plates are cut from the xenopericardium, corresponding to the size of the aortic root, in which during surgery the mouths of the coronary the arteries cut holes, then fix the plates to the mouths of the coronary arteries, and then hem them with a double-row mattress suture office support frame aortic valve and depending on the step size and strength yarn tension under the constant control of the degree of narrowing diameter regulate the annulus fibrosus and the aortic root, comparing valve leaflets relative to one another.

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